ECCO-EFCCA Patient Guidelines on Crohn’s Disease (CD)

Recommendations

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Overall, more than 90% of gastroenterologists agree that maintenance therapy after successful cessation of fistula drainage is mandatory. The preferred drugs are thiopurines or anti-TNFs and they should be used for at least one year. Extra-intestinal Manifestations (EIM, Symptoms Related to CD Outside the Bowel) Joint Problems Diagnoses of joint diseases that are associated with IBD are made on clinical grounds based on typical symptoms, and ruling out other specific forms of arthritis. There are two broad types of joint diseases associated with IBD, namely peripheral and axial arthropathy. Peripheral arthritis has two types, namely type 1 and type 2. Type 1 affects large joints (e.g., knees, elbows, and shoulders), coincides with inflammation in the intestines, and happens in 4-17% of CD patients. On the other hand, type 2 affects small joints (e.g., in the hand) and only happens in 2.5% of CD patients. The diagnosis of arthritis is made by observing painful swollen joints and the other diseases that need to be ruled out are osteoarthritis, rheumatoid arthritis, and arthritis associated with connective tissue diseases (e.g., lupus). In addition, medication related causes to be ruled out are arthralgia (i.e. joint pain) caused by withdrawal of steroids, osteonecrosis (i.e. reduced blood flow to the joints) caused by steroids, and infliximabinduced lupus. Meanwhile, axial arthropathy includes sacroiliitis (which occurs in 25-50% of CD patients) and spondylitis (which occurs in 4-10%). Ankylosing spondylitis is characterised by chronic back pain, morning stiffness, limited ability to bend the spine, and, in later stages, reduced chest expansion. The gold standard for diagnosing ankylosing spondylitis is MRI because it can detect inflammation before bone lesions occur. Peripheral arthritis usually affects the large joints in the limbs. It can be treated with physiotherapy, NSAIDs on a short-term basis, and local steroid injections. The emphasis should be on treating the underlying CD. Sulfasalazine may help to treat persistent peripheral arthritis. Recommendations for the treatment of CD-related arthropathy (i.e. joint disease) are based on studies in spondyloarthropathy (i.e. joint disease), predominantly ankylosing spondylitis (i.e. arthritis in the spine). No well-designed studies have been performed in the domain of IBD and so the recommendations in this domain are inferred from other diseases. In peripheral arthritis, the treatment of the underlying CD using corticosteroids, immunomodulators and anti-TNFs should also relieve the symptoms. If treating the underlying CD does not alleviate the joint pain then the patient should consider taking NSAIDs short term; whilst NSAIDS can potentially aggravate the underlying CD, the risk of this seems to be low. Physiotherapy and rest can provide symptom relief. The use of COX-2 inhibitors (e.g., etoricoxib and celecoxib) appears safer with a lower risk of disease flare than conventional NSAIDs. Sulfasalazine can be beneficial for large joint arthropathy. Lastly, infliximab can have a very beneficial effect on peripheral arthritis. 14
Axial arthritis causes pain and stiffness in the joints of the lower back. Intensive physiotherapy and NSAIDs are recommended, but long-term treatment with NSAIDs should be avoided due to safety concerns. Anti-TNF is preferred to treat ankylosing spondylitis if the patient does not tolerate NSAIDs or there is no response. Sulfasalazine, methotrexate and thiopurines are ineffective. Recommendations for the treatment of CD-related axial arthritis are based on studies in ankylosing spondylitis (i.e. arthritis in the spine). Intensive physiotherapy and NSAIDs can be used although NSAIDs should be avoided in the long term. Local corticosteroid injections can be considered. Sulfasalazine, methotrexate and azathioprine are not effective for ankylosing spondylitis with axial symptoms. In patients with active ankylosing spondylitis that do not respond to or cannot tolerate NSAIDs, anti-TNF agents are recommended. Adalimumab and infliximab are both proven to be sufficiently safe and effective for treating ankylosing spondylitis. Bone disorders <strong>Patient</strong>s who take corticosteroids or those with reduced bone density should receive calcium and vitamin D supplements. Muscle strength training and quitting smoking are helpful. <strong>Patient</strong>s with fractures should be treated with bisphosphonates, but their ability to prevent fractures is unproven. Routine hormone replacement in postmenopausal women is not recommended due to the risk of side effects. Men with low testosterone may benefit from receiving it medically. Treatment with calcium 500–1000 mg/day and vitamin D (800–1000 IU/day) increases bone density in patients with IBD although it has not been studied whether they prevent fractures in IBD patients. Therefore, a general recommendation of treatment with bisphosphonates on the basis of reduced bone density is not feasible. That being said, postmenopausal women or those with steroid-induced osteoporosis will benefit from them. Overall, in individual patients with low bone density and additional risk factors, treatment should be considered. <strong>Patient</strong>s with chronic active disease should be treated with immunosuppressants, such as azathioprine and anti-TNFs, so they can stay off steroids and reduce the negative effects of their inflammation on their bone density; it has been shown that many CD patients can regain normal bone density after three years of stable remission. Skin manifestations Treatment of erythema nodosum is usually based on that of the underlying CD. Systemic steroids are usually required. Pyoderma gangrenosum is at first treated with systemic steroids, anti-TNF treatment or calcineurin inhibitors. Erythema nodusum (i.e. red lumps on the skin on the shins, thighs, and forearms) usually easily noticed and occurs in about 5-10% of CD patients. It usually occurs when the CD is active. Diagnosis can usually be confirmed without the need for biopsies. Treating the underlying disease using oral steroids is usually needed and if steroids do not work or it relapses regularly, azathioprine and/or infliximab may be added; the need for azathioprine or infliximab is very rare, nonetheless. Pyoderma gangrenosum (i.e. large painful ulcers on the skin) can occur anywhere on the body, including genitals, but the commonest sites are the shins and near stomas. They usually start off being superficial but get deeper with time. Between 0.6% and 2.1% of CD patients get this at some time and it can coincide with the CD disease activity or not coincide with it at all. Pyoderma gangrenosum is a diagnosis of exclusion, which means it 15
Page 1 and 2: ECCO-EFCCA
Page 3 and 4: There is no single test for the dia
Page 5 and 6: Endoscopic biopsies For a reliable
Page 7 and 8: Colonic CD Active CD in the colon s
Page 9 and 10: use of corticosteroids often causes
Page 11 and 12: Obstructive Ileocecal CD Surgery is
Page 13: Surgical treatment of uncomplicated
Page 17 and 18: Glossary Anatomical illustration of
Page 19 and 20: Budesonide Medication A drug that b
Page 21 and 22: sedimentation rate Extensive coliti
Page 23 and 24: descriptor left side of the colon a
Page 25 and 26: Small bowel capsule endoscopy (SBCE
Page 27: translation of the ECCO</st

ECCO-EFCCA Patient Guidelines on Crohn’s Disease (CD)

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